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.: .� County <br /> 411.01:;-- .t Safety and Buildings Division Dane <br /> :11<+a " ?i 1 Wg 201 W.Washington Ave.,P.O.Box 7162 <br /> t o .- i i t i t Sanitary Permit Number(to be fi l l e d in b y C o.)Madison,Wt 53707-7162 <br /> Sanitary Permit Application State TmnsnetronNumber <br /> In accordance with SPS 38321(2),Wis.Mm.Code,submission of this form to the opproprinte govcmtnc nui unit <br /> is required prior to obtaining a sanitary permit.Note Application fonts for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Senates. Petsonal information you provide any be used for secondary <br /> purposes in accordance with the Privacy Law.s.15.04(1 Xmi,Slats. <br /> I. Application Information—Please Print All Information Sun Valley Parkway <br /> Property Owner's Name Parcel 3 Kim&Jason Klein 0508-121-8610-0 <br /> Property Owner's Mailing Address <br /> Property Locution <br /> 6425 Sun Valley Parkway Lot <br /> City,State Zlip Code Phone Number NE 1,4, NE Y.,Section 12 <br /> Belleville,WI C8---'-'�,� T 5 N 8 one) <br /> II.Type of Building(cheek all that . ,) e or W <br /> ®I or2 Focally Dwelling-Number of= '... 4 1 Subdivision Name <br /> / lock if <br /> ❑Public/Commeteial-Describe use / <br /> .// ❑City of <br /> _Y <br /> ❑State Owned'-Describe UseI Number ❑Village of <br /> 14081 ®Town of Montrose <br /> III.Type of Permit: (Check only one heron line A. Complete line B If applicable) <br /> A (2 New System ❑Replacement System ❑Treatmenal-IoldingTank Replacement Only Q Other ModirrcatIon to Ex sting System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ List Previone Pemrit Number and Date Issued <br /> Change of Plumber ❑Permit Trmsfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground 187 At-Crrade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Disposal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersavrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ra*e(gpdsl) Dispersal Area Required is() Dispersal Area Proposed(sf) System Elevation <br /> 600 0.6 1000 1000 97.0' <br /> VI.Tank Info Capeeity in Total if of Manufacturer <br /> Gallons Gallons Units �' o n <br /> New"Myths ExistingTants K a A " A `' °' • <br /> .$A i3 <br /> aU en3 m ED ia, <br /> septic err}tabling Tame 1250 1250 1 Crest x <br /> Dogleg Chamber 750 750 1 Crest x <br /> VII.Responsibility Statement 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P Signature IviP/MPRS Number Business Phone Number <br /> Plumbers Address(Street,City,State,Zi Code <br /> State, CX(e &&4—d/ _.. ---- <br /> _VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Pee Date Isue '''. Issuing zZ;7T❑Owner Given Reason for Denial ! , � 251 \ <br /> IX Conditions of Approval/Reasons for Disapproval ,.r/ <br /> ego-(4.<-7 A7-- E SirF 4M(O '44/<A- /is-R1 .'owrrJO Pf <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t2 a 11 Inches to size <br /> SBD-6398(R.11/11) <br /> • <br />